IBCLC Coding, Documentation and Billing for In-Network IBCLCs      Time to Get Paid!

 Frequently Asked Questions

In 2013, my blood, sweat, time and energy went into creating a Crash Course for my colleagues to help combat the stress and frustrations with In-Network opportunities. My manual is designed to teach you the aspects of coding, documentation and billing as an In-Network provider in a way that is easy to understand.  This FAQ page is just the beginning.  IBCLCs email me with billing questions and as this process unfolds I will build my website and share.

How do I start?

  1. Go to www.paperlessibclc.com and buy and download the my Coding, Documentation and Billing Manual sold there and start reading.
  2. Decide if you are using your social security number for tax and enrollment purposes or get Federal Tax ID Number also called an EIN @ www.irs.gov
  3. Next go online to Aetna, Blue Cross and any other insurance company in your state that is asking and sign up to be a provider.
  4. After you sign up online, you will be issued a CAQH number and be invited to CAQH or a credentialing company set up by the insurance company to credential you so you can sign a contract as a health care provider.
  5. You will then hopefully be contacted by a representative from the insurance company and asked to sign a contract. If an initial contact takes too long, be persistent.  
  6. After you sign a contract, you will be listed on the company’s website as a provider and you can ask for the “Market Fee Schedule for providers” or the amounts the insurers will reimburse you for the procedures you do. They will not disclose that before you join them. 
  7. With that in hand, you will then sit down with my manual and prepare, do consults, code, document, bill and get paid.
  1. Why can’t I find out what I will be reimbursed before I sign a contract?

Because you can’t, so do not rely on getting the correct procedure code information from a phone call either. You can look up the “relative value unit” for a certain procedure code for your zip code but you may be billing out multiple procedure codes together so once you understand the process you will learn how to get the maximum credit for your services. There are websites that can tell you the usual and customary fees for your zip code. www.fairhealthconsumer.org is one of them.

Is Aetna my only In-Network option?

Yes and no, it depends upon your state. Many aspects of the Affordable Care Act will be rolling out until 2020. Aetna is a national company that has asked for IBCLCs to enroll in all states.  Other insures may be asking, but will vary state by state. So far, for the Blues, I have found that Pennsylvania, Nebraska Blue and BCBS of Arizona have In-Network IBCLCs. United Health Care in some states is asking for providers to join. Tricare, a government program, has some IBCLCs in-network. You are encouraged to contact each insurer or simply enroll online for as many insurers that cover you area. See what happens.

I am hearing I will only get paid for “Lactation Classes” not consultations?

There are very few codes that have the word lactation in the name. Procedure codes that apply to what we do in a consult do not really exist yet. What do I mean by that? No coding exists for an interactive feeding visit for two patients, two sets of issues, in the same room, in the same day. So we are being asked to use a variety of counseling, consultation and Evaluation and Management coding for our services, in most cases for Mom. Some insurers offer reimbursement for special S codes for a “non-physician provider” for lactation classes. “S” codes are national, non-Medicare codes that may be used by commercial insurance companies such as Blue Cross-Blue Shield and by state Medicaid agencies. 

S9443 – Lactation classes, non-physician provider, per session

S9444 – Parenting classes, non-physician provider, per session

S9445 – Patient education, not otherwise classified, non-physician provider, individual, per session

S9446 – Patient education, not otherwise classified, non-physician provider, group, per session

Based upon your location in the country and how that insurer defines a "class," they reimburse between $12 to $250 dollars!

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